Recent studies have introduced elevated lipoprotein(a) (Lp(a)) as a risk factor for coronary heart disease (CHD). This study investigated whether the addition of Lp(a) as a novel biomarker to the Framingham Risk Score (FRS) model improves CHD risk prediction.The study included 1101 Iranian subjects (443 non-diabetic and 658 diabetic patients) who were followed for 10 years (2003–2013). Lp(a) levels and CHD events were recorded for each participant.P value: 0.007).The Net Reclassification Index (NRI) after adding Lp(a) to the FRS model was 19.57% and the discrimination slope was improved (0.160 vs. 0.173). The Akaike Information Criterion (AIC), a measure of model complexity, decreased significantly after adding Lp(a) to the FRS model  to the FRS model improves CHD risk prediction in an Iranian population without making the model too complex. This could help clinicians to better identify individuals who are at risk of developing CHD and to implement appropriate preventive measures. Coronary heart disease (CHD) is the leading cause of death worldwide and a major risk factor for disability-adjusted life years, especially among young people , 2.Hypertension, dyslipidemia, tobacco smoking, diabetes, physical inactivity, and diet are known as some conventional risk factors for CHD . RecentlFramingham Risk Score (FRS) which is one of the scoring systems used for the evaluation and prediction of CHD in 10 years, categorizes patients as “high”, “intermediate,” and “low” risk. FRS variables include some conventional risk factors such as age, diabetes, smoking, hypertension, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) –8. DespiThere are already studies regarding the adaptation of the Framingham model for cardiovascular disorder in different populations, showing that the model can be adjusted slightly for different populations to better accommodate the differences , 12. AlsLp(a) is an LDL-like particle that contains a hydrophilic, highly glycosylated protein called apolipoprotein(a) bound to apolipoprotein B100 by a disulfide bridge. Lp(a) plays a significant role in atherosclerosis as an independent risk factor for cardiovascular diseases , 16.Recent studies suggested that Lp(a) levels were independently associated with an increased risk of coronary artery disease, even after accounting for traditional risk factors such as LDL-C levels. Incorporating Lp(a) measurement into risk stratification models significantly could improve risk prediction and potentially lead to identifying individuals who may benefit from more aggressive personalized preventive strategies , 18.A statistical measure used to evaluate the performance of predictive models is the area under the curve (AUC) with the range of 0.5 (no discrimination) to 1.0 (perfect discrimination) which represents the overall discriminatory ability of a model in distinguishing between individuals with and without the outcome of interest (CHD event in this study). The net reclassification index (NRI) and integrated discrimination index (IDI) are another statistical measure that assesses the improvement in risk prediction when adding a new marker to an existing model. NRI takes into account the correct reclassification of individuals into higher or lower-risk categories, as well as incorrect reclassification. It calculates the net proportion of individuals who are correctly reclassified into a higher risk category minus the net proportion of individuals who are incorrectly reclassified into a lower risk category with the range from − 2 to + 2. IDI quantifies the difference in average predicted risks between individuals with and without events and ranges from − 1 to + 1. Positive values indicate improved prediction with the addition of the new marker. NRI and IDI can be used alongside the AUC to further evaluate and compare different models in predicting CHD –21.This study aims to investigate whether adding Lp(a) to the FRS model improves its predictive value, as measured by NRI and IDI.In this retrospective cohort study, the target population was selected from the patients who were referred to the endocrinology and metabolism clinic of Vali Asr Hospital in Tehran, Iran, between 2003 and 2013. We included all the patients who underwent coronary angiography for highly suspected CHD. The patients with missing data on lipid profile and also the subjects with diabetes mellitus who were Insulin-dependent, type 1, secondary, or pancreatitis-related with a prior history of other endocrine diseases (except their diabetes status) were excluded. The diabetic patients included in the study were on oral antidiabetic agents.Informed consent was obtained from each patient and the study was reviewed and approved by the board of medical ethics at Tehran University of Medical Sciences with the code of IR.TUMS.REC.1394.412.The diabetes was diagnosed according to the American Diabetes Association criteria .Finally, 1101 patients were enrolled in this study (two sub-groups: 443 non-diabetic and 658 diabetic patients).Age, gender, weight (kg), height (cm), waist circumference (cm), systolic and diastolic blood pressure  (mmHg), and medical history of the patients were recorded.Waist circumference (WC) is defined as the midline between the lowest rib and the iliac crest.SBP and DBP were measured from both arms after 15 min of rest in the supine position and the mean value was recorded. Venous blood samples were collected after 12 h of overnight fasting.To assess fasting plasma glucose (FPG) and 2-hour post-prandial plasma glucose (2hPP), a glucose oxidase assay was used. Lipid profiles including total cholesterol, HDL-C, LDL-C, and triglyceride (TG) were measured using a direct enzymatic method .To measure fasting insulin, radioimmunoassay using separate specific antibodies was utilized . Serum creatinine was assessed by the Jaffe method. HbA1c was evaluated by high-performance liquid chromatography . Also, Lp(a) was measured by turbidometry method .2) was calculated as Weight/Height2 and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) as [FPG (mg/dL) ×Fasting Insulin(U/L)] / 405. Metabolic syndrome was determined according to the nationally modified version of the International Diabetes Federation (Modified- IDF) criteria [Body Mass Index , improved AIC, BIC, and − 2 log-likelihood, and a small improvement in the AUC of the ROC curve. While the increase in AUC was not statistically significant (P = 0.200), it is important to note that it is a step towards improving the model. We expect that the addition of more novel biomarkers, one by one, will lead to a significant improvement in the model through these small increases for each biomarker. We also observed increases in discrimination slope and NRI. The details of the models are listed in Table We used two models to predict the risk of CHD in our subjects: the conventional FRS model and the FRS model with Lp(a) added. We found that the model with Lp(a) had a higher likelihood ratio ). Our study showed that adding Lp(a) to a model based on conventional risk factors improved NRI and IDI in the Iranian population. It also decreased the model complexity.Unexpectedly, patients with CHD had lower TG, LDL-C, and total cholesterol levels. This may be due to treatment effects, lifestyle modifications, or early detection and treatment of secondary causes of dyslipidemia, such as hypothyroidism, during CHD management.A previous study of 826 subjects aged 45 to 84 years in Bruneck, Italy, found that elevated Lp(a) predicts 15-year cardiovascular disease (CVD) outcomes, and that adding Lp(a) to the FRS model improves CVD risk prediction. The study showed that the NRI related to Lp(a) was 17.1% and 22.5% for patients with and without CVD, respectively, and 39.6% overall .Another study on 8720 Danish participants over 17 years which was in line with our study showed that the addition of extreme levels of Lp(a) to the baseline model improved CHD event classification. In other words, after adding Lp(a) to the conventional model at the levels of ≥ 80th (47 mg/dl) and ≥ 95th (115 mg/dl) percentiles, 23% and 39% of patients with myocardial infarction (MI) and 12% and 25% of patients with CHD were correctly reclassified. For these two cut points, the NRI was 16% and 23% for MI and 3% and 6% for CHD, respectively. However, Lp(a) addition over the entire concentration did not significantly change the NRI. Discrimination was improved by IDIs for MI and CHD in extreme levels of Lp(a), while C-index changes remained insignificant .A study that assessed three cohorts of women including the Women’s Health Study , Women’s Health Initiative Observational Study , and the Justification for Use of Statins in Prevention (JUPITER) trial  found that increased Lp(a) is associated with higher CVD risk only among patients with high total cholesterol (above 220 mg/dL). According to the mentioned study, prediction improvement among women also was minimal. In contrast, JUPITER showed a strong association of Lp(a) with CVD among men with low total cholesterol levels .A recent retrospective study that enrolled 1395 patients, found better capability of an existing model for predicting coronary artery disease after adding Lp(a) compared to other lipid parameters. The new model which incorporated Lp(a) achieved an NRI of 12.8% and significant improvement in accuracy, measured by IDI .One of the strengths of our study is that it was conducted in a Middle Eastern population and there are not many studies in this population on this issue. However, there are certain limitations. The study was done on retrospective data. Most of the patients with CHD were on Statin and/or other anti-lipid agents which may affect the level of Lp(a) and other lipid parameters. We only included one novel biomarker in this study. The study lacked data on the details of the major adverse cardiac events. For future studies, we will also continue enrolling patients to assess the continued effects of Lp(a) and other novel biomarkers, in a cohort with an increased sample size and increased number of events, to further improve the statistical power of our study as well.This study showed that adding Lp(a) to the FRS model compared to the conventional FRS is superior in risk stratification, discrimination, and net reclassification in a sample of the Iranian population. For future studies, we’d recommend prospective designs with a larger sample size including more novel biomarkers, in hopes of better establishing predictive models for our population.


E-cigarettes pose significant risks to youth, but smokers may benefit from switching to e-cigarettes by reducing their exposure to toxicants, which creates a challenge for the Food and Drug Administration (FDA) in regulating e-cigarettes to protect population health. This study aims to develop e-liquid product standards for nicotine form and concentration that reduce the appeal of e-cigarettes to young people while keeping e-cigarettes available as a safer alternative for smokers.A single-visit, double-blinded, randomized crossover design will be used to examine the effects of e-liquids with varying fractions of free-base nicotine  among a sample of 66 young adult EC users and 66 older adult smokers, across ecologically valid total nicotine concentrations (20 mg or 50 mg/mL).A 2-puff session will be conducted to test each of the 10 e-liquids in randomly assigned sequences, followed by a 10-minute washout period and participant ratings on appeal and sensory attributes such as throat hit and harshness, as well as behavioral intentions for continued use. Generalized linear mixed models will be used to determine a free-base nicotine level that has limited or no appeal to young adult e-cigarette users while remaining acceptable to smokers.This study will provide the FDA with scientific evidence regarding the effect of product standards that mandate a minimum threshold for the fraction of free-base nicotine.NCT05864586.The study is registered on clinicaltrials.gov under the identifier  Viewing ECs through this lens, the FDA needs robust evidence demonstrating how to regulate ECs based on these two competing goals that must be aligned: 1) allowing ECs to remain on the market as appealing, potentially less harmful substitutes for current smokers, and 2) reducing their appeal and addictiveness for young people.Regulating e-cigarettes (ECs) is challenging. While ECs pose significant risks to young people by increasing the risk of nicotine initiation and sustained nicotine addiction  and use The US Congress and FDA have already implemented several regulatory efforts to curb youth EC use, including: increasing the federal minimum age requirements to purchase tobacco products (including ECs) to 21 years ; banningTo protect young people and still offer smokers a potentially less harmful alternative, the FDA could establish an e-liquid nicotine product standard that sets a minimum level of FB nicotine content that is unappealing/minimally appealing to young people and non-users but still satisfies nicotine craving in adult smokers. Recent evidence suggests that young exclusive EC users prefer “smoother” e-liquids with very low levels of FB nicotine, but smokers and dual users prefer some level of throat irritation , or whatTherefore, the purpose of the present study is to determine this minimum FB nicotine level  across two ecologically valid nicotine concentrations (20 mg/mL and 50 mg/mL) among a sample of young adult EC users with minimal/no history of smoking as well as older adult smokers. We hypothesize that with increasing FB levels , ECs will be too harsh for exclusive young adult EC users but not for adult smokers, especially at the higher nicotine concentration.Using a single-visit, double-blind, randomized crossover trial design the study will examine the effects of e-liquids with varying levels of FB nicotine  at two nicotine concentrations (20 or 50 mg/mL) on appeal among young adult EC users with little or no history of smoking (n = 66) and older adult smokers (n = 66). The schedule of enrollment, interventions, and assessments is shown in Study visits will take place in the Ohio State University Comprehensive Cancer Center (OSUCCC)’s Center for Tobacco Research (CTR) in Columbus, Ohio. All study visits will be conducted in smoking/vaping rooms under negative pressure.The study team will prepare 10 tobacco-flavored e-liquids, which vary in FB nicotine  and concentration (20 or 50 mg/mL) and contain commercially available tobacco flavorings, benzoic acid, glycerol (vegetable derived), and propylene glycol see . The FB The study is planned to enroll participants from June 1, 2023 to December 31, 2023. This is a one-time visit study, and there will be no follow-up required. A sample of healthy, young adults who exclusively use ECs and have no or minimal smoking history (n = 66) and older adults (25–50 years) who smoke (n = 66) will be recruited for the study. Participants will be recruited from the general public, using targeted online and social media advertisements, flyers, and word-of-mouth marketing in the Columbus metropolitan area. Various online and social media platforms will be used to distribute advertisements. Participants will be screened initially through an online screener linked to our study advertisement, then over the telephone. Those meeting the following eligibility criteria will be asked to participate and will be compensated for their time ($125/visit). Inclusion criteria: 1) current exclusive young adult EC user (daily use) for at least the past 3 months (confirmed by urinary cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) between 21–24 years old inclusive, with no or minimal history of smoking cigarettes (<10 cigarettes in lifetime), or current older adult smoker (daily use and ≥100 cigarettes in lifetime) between 25–50 years old inclusive, with interest in trying an EC; 2) willing to abstain from all nicotine product use for 12 hours prior to the study visits; and 3) read and speak English. Exclusion criteria: 1) currently attempting to quit nicotine or tobacco products; 2) currently pregnant (will be verified with a urine pregnancy test), planning to become pregnant, or breastfeeding; 3) current or past use of tobacco products other than ECs or cigarettes ; 4) self-reported diagnosis of lung disease including asthma, cystic fibrosis, or chronic obstructive pulmonary disease; 5) self-reported new or unstable cardiovascular disease diagnosed within the past 12 months.Each participant will complete a single, solo laboratory visit for a maximum of 3 hours see . ParticiAfter participants complete questionnaires on sociodemographics, tobacco use history, and EC and cigarette dependence, 10 vaping sessions will take place. In each vaping session, participants will inhale two puffs from the study EC device, loaded with one of the 10 research conditions (5 freebase nicotine fractions x 2 nicotine concentrations). Participants will be told to inhale for at least 1 second per puff, while other puffing parameters  will not be controlled. Pre-filled and weighed e-liquid pods will be provided to participants in random order. The assigned randomization sequences of the study e-liquids will be generated by a statistician using SAS 9.4. Permuted block randomization, stratified by use (young adult EC users vs older adult smokers), will be employed to ensure that each research condition is sampled an equal number of times in each position. Study staff enrolling participants and collecting data will remain blinded to each participant’s assigned study e-liquids throughout the course of the study.There will be a 10-minute washout period between conditions to minimize carryover effects, where participants will be instructed to rinse their mouth and spit at least three times with room-temperature water . The wasBehavioral Intentions for continued use will be assessed by asking participants how likely they are to: 1) try the product again, 2) purchase the product for regular use, and 3) use the product regularly if this were the only e-cigarette available. Response options will range from 1 “extremely unlikely” to 7 “extremely likely” [The primary outcome measures are behavioral intentions for continued use, the intensity of sensory attributes, and the degree of liking or disliking of each e-liquid.  likely” . The int likely” , 29. Par likely”  with a vThe secondary outcome measures include the subjective appeal and overall acceptance of each e-liquid. Subjective appeal will be assessed using the Adapted Drug Effects/Liking Questionnaire  and the Statistical analysis will be conducted using SAS 9.4 . Participant demographic and other characteristics will be summarized by the study arm. Continuous variables will be reported as mean ± standard deviation and compared using t-tests, whilst categorical variables will be reported as counts and proportions and compared using chi-squared tests. Transformations will be applied to normalize the distribution and stabilize the residual variance where appropriate.To determine a nicotine fraction limit that is satisfying to smokers while minimally appealing to young adult EC users, generalized linear mixed models will be used to evaluate appeal , which include demographic and smoking history as covariates, random subject effects, main effects for usage group (smokers versus EC users), FB fraction  and concentration , and interactions between usage group and each of the condition parameter variables . A significant interaction between the usage group and a condition parameter variable would suggest that the variable influences the two user groups differently with respect to their appeal. Interactions between condition parameter variables will also be explored. Various link functions and distributions will be employed to complement the data structures for each of the outcomes, including ordinal logistic regression.Given our goal to find combinations of the condition parameter that are sufficiently satisfying for smokers but do not appeal to young adult EC users, condition combinations will also be directly compared between study arms to identify the condition parameter combinations that result in the greatest difference in appeal between the two user groups. These comparisons will be made using t-tests or Wilcoxon rank-sum tests as appropriate for the structure of the data. Lastly, carryover effects will be explored by estimating the interaction between a given condition and its preceding treatment, and period effects will be examined by testing the interaction between treatment and order. A significance level of p = 0.01 will be used, given the various measurements tested.A total of 132 participants will be recruited, including young adult e-cigarette (EC) users with minimal or no history of smoking (n = 66) and older adult smokers (n = 66). Conservatively, 10% of 132 participants are assumed to need to be replaced post hoc with another participant due to failing to abstain from nicotine use prior to the study visit. With 120 participants, a correlation of 0.5, and an alpha of 0.01, a two-sided paired t-test has 80% power to detect an effect size of 0.32 standard deviations of the measurement for the concentration main effect. For the FB fraction main effect, the model has 80% power to identify a slope of 0.31 with 120 participants with an alpha value of 0.01. The effect sizes are conservative, given that a previous study , which iStudy data will be collected, managed, and secured using REDCap, an electronic data collection tool hosted at the OSUCCC, which will be accessible to authorized study personnel who have the necessary password(s). Each participant will be granted a unique identifying number for the study (study ID) and only the research ID will be used to identify all study data. Tablets provided by OSU will be used to enter electronic data , which will be collected directly from participants. All computer systems will be password-protected to prevent unauthorized access, and all network-based inter-site communications of confidential data will be encrypted. Access to information stored on a computer will require concurrent knowledge of the data format, computer language, file name, and passwords. Participant information will be accessible only to research staff who are pledged to confidentiality and have received training in the ethical conduct of research . Physical materials will be stored in a locked file cabinet, office, or suite at the CTR.Study visits will take place in a secure laboratory setting at the CTR where access is limited to study personnel, and researchers will work with only one participant at a time to protect participants’ privacy. Since participants may perceive questions on EC use as intrusive, participants will be informed of the nature of questions in advance.Since current EC users and adult smokers will be recruited, the participants are already smoking or using ECs and will only be asked to use a fully characterized EC device and e-liquids for which an FDA ITP was submitted and will be "approved" . The risk of side effects and adverse events associated with the use of ECs is quite low. ECs are commercially available in the US without a prescription. Lab studies of toxicant exposure suggest that ECs incur no greater risk to health than combustible cigarettes. In general, ECs have lower levels of harmful and potentially harmful constituents than cigarettes but are not 100% safe . To dateDuring the study period, all participants will be screened for general medical precautions  and monitored for adverse events. Any serious adverse events will be reported to the study MPI and subsequently to the Ohio State University Institutional Review Board (IRB). Participants who experience a serious adverse event or have a cardiovascular or pulmonary event will be withdrawn from participation. Blood will be drawn by a trained nurse; only sterile tools will be used, and the participant’s skin will be cleansed with an alcohol wipe at the location of the needle stick. Following the completion of the study, we will encourage participants to quit smoking and/or stop using ECs. Participants will be provided with a post-study information sheet, which includes information about the Ohio Tobacco Quit Line service that offers nicotine replacement therapy resources.This study has been registered with clinicaltrials.gov under the identifier NCT05864586. This study was reviewed and approved by the Ohio State University Cancer IRB under Study Number 2022C0207 on 4/10/2023. Oral and written explanations of the study and REDCap will be utilized for receiving informed consent and a legally valid signature. During the consent procedure, the voluntary nature of the study and the participant’s right to withdraw at any time will be emphasized, and a written copy of the informed consent will be given to the participant at the moment of consent for them to keep. Personnel approved by the IRB will collect informed consent. Any protocol revisions will be reported to the OSU Cancer IRB and ClinicalTrials.gov and will be noted in manuscripts.The study is planned to enroll participants from May 2023 to December 2023.There is an urgent public health need to prevent young people from initiating EC use. However, the potential of ECs to help current smokers quit smoking makes their regulation challenging. While regulatory efforts have been implemented to curb youth use, including banning the sale of flavored cartridge-based ECs, there is a need to regulate nicotine dimensions that make youth users dependent on ECs. This study will help the FDA establish e-liquid nicotine product standards that minimize the appeal of ECs to youth while satisfying adult smokers’ nicotine craving by examining the impact of nicotine form and concentration on sensory perceptions and EC liking.There are limitations of the study to be acknowledged. First, there is a risk of carryover effect because participants will test 10 e-liquids in a single laboratory visit although a 10-minute washout period will follow sampling each e-liquid to minimize the potential carryover effects. Carryover effects will be explored by estimating the interaction of a given condition with the preceding condition. Also, the 10 test liquids will all be tobacco-flavored, thus flavor effects cannot be assessed. This design was chosen to minimize participant burden and based on the fact that the impact of nicotine concentration on sensory experiences was consistent across different flavors . Still, Strengths of the study include the use of standardized scales to assess the sensory effects of nicotine , 30, theS1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.


The Oxford Elbow Score (OES) and the short version of Disabilities of Arms, Shoulder and Hand (QuickDASH) are common patient-reported outcomes for people with elbow problems. Our primary objective was to define thresholds for the Minimal Important Difference (MID) and Patient-Acceptable Symptom State (PASS) for the OES and QuickDASH. The secondary aim was to compare the longitudinal validity of these outcome measures.We recruited 97 patients with clinically-diagnosed tennis elbow for a prospective observational cohort study in a pragmatic clinical setting. Fifty-five participants received no specific intervention, 14 underwent surgery (11 as primary treatment and 4 during follow-up), and 28 received either botulinum toxin injection or platelet rich plasma injection. We collected OES  and QuickDASH , and global rating of change  at six weeks, three months, six months and 12 months. We defined MID and PASS values using three approaches. To assess the longitudinal validity of the measures, we calculated the Spearman’s correlation coefficient between the change in the outcome scores and external transition anchor question, and the Area Under the Curve (AUC) from a receiver operating characteristics (ROC) analysis. To assess signal-to-noise ratio, we calculated standardized response means.Depending on the method, MID values ranged from 16 to 21 for OES Pain; 10 to 17 for OES Function; 14 to 28 for OES Social-psychological; 14 to 20 for OES Total score, and − 7 to -9 for QuickDASH. Patient-Acceptable Symptom State (PASS) cut offs were 74 to 84 for OES Pain; 88 to 91 for OES Function; 75 to 78 with OES Social-psychological; 80 to 81 with OES Total score and 19 to 23 with Quick-DASH. OES had stronger correlations with the anchor items, and AUC values suggested superior discrimination (between improved and not improved) compared with QuickDASH. OES also had superior signal-to-noise ratio compared with QuickDASH.The study provides MID and PASS values for OES and QuickDASH. Due to better longitudinal validity, OES may be a better choice for clinical trials.ClinicalTrials.gov NCT02425982 .The online version contains supplementary material available at 10.1186/s12874-023-01934-4. Elbow-specific Oxford Elbow Score (OES), and the short version of the upper limb-specific Disabilities of Arms, Shoulder and Hand (QuickDASH) both use a question-and-response format to convert a complex multidimensional health state into a single metric scale , 2. Whilthe smallest difference in score in the outcome of interest that informed patients or informed proxies perceive as important, either beneficial or harmful, and that would lead the patient or clinician to consider a change in the management”  – [mean change of ‘unchanged’]) (3) ROC curve method (closest point to the upper left corner) dichotomizing between ‘no change’ and ‘little better’ and excluding participants with responses ‘little worse’ or ‘much worse’ [We determined the MID using three different anchor-based methods: h worse’ .For PASS, we used 75th percentile method and ROC method from the 6-month and 12-month time points . In the To assess the signal-to-noise ratio, we calculated standardized response mean (SRM) for both outcomes as mean score change (between baseline and 1 year follow-up) divided by the SD of the change. SRM is the ratio of signal to noise. A SRM of 0.2 can be considered to indicate low responsiveness; 0.5 moderate and 0.8 as large responsiveness .We recruited 97 participants with clinically diagnosed tennis elbow Table . At baseMost n = 55; 61%) participants did not receive any specific intervention initially; four participants received surgery during follow-up. Smoking was fairly common (27%) among the participants, and most (71%) had received at least one corticosteroid injection before enrolment (range 1 to 6 injections) . Both QuickDASH and OES captured the perceived change adequately, but OES change correlated more strongly with the transition anchor compared with QuickDASH change , and accordingly, OES discriminated better Table . CorrelaFor both OES and QuickDASH change scores, the correlations with the transition anchor (GRC) increased at longer follow-up. After three months, the change scores correlated more strongly with the current state than with change score . The change scores correlated with the baseline score only for OES at 24 months .MID = minimal clinically important difference, ROC = receiver operating characteristics, OES = The Oxford Elbow Score, DASH = Disabilities of Arms, Shoulder and Hand, CI = Confidence interval.MID and PASS estimates varied depending on the calculation method Tables  and 5. TIn people with tennis elbow, the elbow-specific OES better captured the change in the perceived health than did the upper extremity-specific QuickDASH. The OES better discriminated people who improved from people who reported no change, and the MID and PASS values are therefore more credible for OES than QuickDASH. OES also had superior signal-to-noise ratio, indicating that smaller sample sizes may be used in clinical trials to identify or exclude clinically-relevant differences when OES is used compared to QuickDASH.The MID reflects the difference in score that informed patients perceive as important , and that would lead the patient or clinician to consider a change in management. The methods impacted the MID values adding a layer of uncertainty to the interpretation of the results. If we determine the MID using the mean change in people reporting being ‘little better’, approximately half of the participants who reported feeling better will be classified as ‘not improved’— a relatively high rate of misclassification. ROC analysis optimizes the cut off, therefore MID from ROC analysis is more valid for discrimination purposes. Due to the impact of outliers, the ROC method is also more robust to skewed distributions compared to the mean change method or the mean difference of change method. However, ROC analysis is affected by the prevalence of people who report improvement. With larger prevalence, the MID values tend to be larger . There iWe propose that differences that are smaller than the lowest values from our study  are judged as not meaningful in people with tennis elbow. For example, authors of a trial or meta-analysis should conclude that the intervention does not provide clinically-important benefits only if the treatment effect confidence intervals are below the smallest provided values. Conversely, higher differences than the highest values  should be considered indicating relevant benefits. When the difference is within the range of possible MID or PASS values, some uncertainty regarding the conclusions is appropriate.Our MID estimates correspond reasonably well with the previous studies. The developers of the OES found MID values of 9, 18, and 18 points with pain, function, and social-psychological scale respectively in a heterogenous population undergoing surgery for elbow complaints. One in ten patients in their sample received surgery for tennis elbow . AnotherPatient accepted symptom state is a cut off for PROM beyond which people consider being well . In our Recall bias affected the patient global improvement assessment beyond three months. When participants were asked to report whether they were better compared to baseline, their responses were more closely associated with their current status than how their condition had changed. This is typical with musculoskeletal conditions . CliniciThis study determined credible MID and PASS values that can be used to interpret trial results. Comparison of longitudinal validity of OES and QuickDASH in tennis elbow patients suggests that although the performance of QuickDASH is acceptable, OES has better signal-to-noise ratio and better longitudinal validity. The OES may be better option as an outcome measure in clinical trials.Below is the link to the electronic supplementary material.Supplementary Material 1


Bariatric surgery has emerged as a highly effective option for individuals with obesity, offering significant and sustainable weight loss outcomes. This surgical approach involves various procedures that alter the anatomy of the gastrointestinal tract, leading to reduced food intake and nutrient absorption. Established procedures such as sleeve gastrectomy, gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch have proven track records. In contrast, emerging options like intragastric balloons, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further investigation. Numerous studies have highlighted the remarkable benefits of bariatric surgery, not only in weight loss but also in the resolution of obesity-related comorbidities and significant improvements in quality of life. However, successful outcomes rely on a multidisciplinary approach, encompassing preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustained weight loss and positive long-term results. As bariatric surgery continues to evolve, tailored procedures based on individual needs and ongoing research hold the potential for even more refined and effective approaches. Through this ongoing advancement, bariatric surgery is poised to offer improved patient outcomes, transforming lives for those grappling with the challenges of obesity. HighlightsBariatric surgery has proven to be highly effective in providing substantial and sustainable weight loss outcomes for individuals struggling with obesity.Bariatric surgery not only aids in weight loss but also resolves obesity-related comorbidities and significantly improves patients’ quality of life. Numerous studies have highlighted the remarkable benefits of improving overall health and well-being.Successful outcomes in bariatric surgery depend on a comprehensive multidisciplinary approach. This involves preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustaining weight loss and achieving positive long-term results.1. These conditions are characterized by abnormal or excessive fat accumulation, which can adversely affect an individual’s overall health and quality of life1. To classify overweight and obesity, the Body Mass Index (BMI) has emerged as a widely used tool, calculated by dividing an individual’s weight in kilograms by the square of their height in meters (kg/m2). In adults, a BMI falling within the range of 18.5–24.9 kg/m2 is considered normal, while a BMI equal to or greater than 25 kg/m2 is categorized as overweight, and a BMI of 30 kg/m2 or higher indicates obesity2. For children and adolescents aged 2–18, overweight is defined as a BMI between the 85th and 94th percentiles3. At the same time, a BMI represents obesity at or above the 95th percentile for the individual’s sex and age3. Over the past four decades, the prevalence of obesity has witnessed a worrisome escalation, affecting both the young and the adult populations alike4. Childhood obesity rates have surged from less than 1% to 6–8%, while adult obesity has risen from 3% to 11% among males and 6% to 15% among females4. Currently, an estimated 1.5 billion adults worldwide grapple with the burdens of being overweight or obese, and this number is projected to soar to 3 billion by 2030, underscoring the urgent need for effective interventions2.The prevalence of overweight and obesity has reached alarming proportions globally, posing significant global challenges to global health systems2. In addition to the immediate health impacts, children with obesity face a heightened risk of long-term adverse outcomes, including premature mortality, disability, respiratory complications, fractures, and early-onset chronic medical conditions like hypertension, cardiovascular disease, insulin resistance, and psychological disorders2. The cumulative impact of obesity has spurred considerable concern among healthcare professionals and policymakers, necessitating comprehensive and innovative strategies to curb this growing epidemic3.The health consequences of obesity are profound and far-reaching, encompassing an increased risk of cardiovascular diseases , type 2 diabetes mellitus, musculoskeletal disorders, and certain cancers5. While previous reviews have explored the efficacy of bariatric surgery in addressing obesity, this study seeks to provide an up-to-date and comprehensive analysis of the latest advancements in this field. By consolidating evidence from recent research, we aim to identify novel approaches and emerging techniques that promise to optimize surgical outcomes and improve long-term patient well-being.The escalating prevalence of overweight and obesity has become a pressing global health challenge, demanding effective interventions to address its significant impact on public health. Bariatric surgery has emerged as a promising therapeutic avenue for severely obese individuals, offering substantial weight loss and improvements in associated comorbiditiesWe conducted a comprehensive narrative review to explore recent advances in bariatric surgery as a weight loss procedure. Our primary objectives were to identify and analyze the latest developments in bariatric surgery techniques, evaluate their efficacy, safety, and impact on patient outcomes and quality of life, and propose potential areas of future research to enhance the field.We conducted an exhaustive literature search to identify relevant studies and publications using databases such as PubMed, MEDLINE, Scopus, Web of Science, and Google Scholar. We used combinations of keywords and Medical Subject Headings (MeSH) terms related to bariatric surgery, obesity, weight loss, surgical techniques, patient outcomes, and quality of life.They should be published in peer-reviewed journals and written in English.The studies should focus on recent advances in bariatric surgery, that is, studies published within the last 10 years.Studies reporting original research, clinical trials, systematic reviews, and meta-analyses.Studies providing data on patient outcomes, safety, or quality of life after bariatric surgery were included.For inclusion in the review, articles must meet the following criteria:Were published more than 10 years ago.Are written in languages other than English.Primarily focus on nonsurgical weight loss interventions or non-bariatric surgical procedures.Comprise case reports or letters to the editor without original data.On the other hand, studies were excluded if they:Two independent reviewers extracted data using a predefined data extraction form. Findings from the selected studies were synthesized and presented descriptively. Our review emphasized identifying common trends, gaps in the literature, and areas of innovation in bariatric surgery.7. It involves vascular attachment division, gastric fundus detachment, posterior gastric artery ligation, and stapling near the pylorus, followed by leak testing and omental suturing for leakage prevention9. LSG induces weight loss by reducing gastric volume, altering hormonal levels (particularly ghrelin and peptide YY), and changing gastric motility11. Studies by Durmush et al.12 reported percentage of excess weight loss (%EWL) of 67.1% at 6 months, 81.2% at 1 year, and 83.8% at 2 years, with improved comorbidities. Radu Neagoe et al. reported %EWL of 41.8% at 3 months and 64.1% at 6 months, with favorable outcomes for type 2 diabetes mellitus (T2DM) and hypertension13. Complications include bleeding, leakage, abscess formation, and late complications like gastric stenosis, nutrient deficiencies, pouch migration, and exacerbated gastroesophageal reflux disease (GERD)14.Laparoscopic Sleeve Gastrectomy (LSG) is a prominent bariatric procedure that reshapes the stomach into a narrow, tubular structure using five or six upper abdomen ports16. Roux-en-Y gastric bypass (RYGB) results in significant body weight loss due to reduced eating, increased energy expenditure, nutrient limitations, and potentially altered metabolic efficiency17. Weight loss averages around 77% of excess body weight at 1 year, with high-resolution rates for preoperative comorbidities, especially diabetes mellitus17. However, long-term weight loss varies between 34% and 80.2% %EWL 10 years post-surgery, and complications include wound infections, respiratory issues, hemorrhage, leakage, obstruction, hernia, gallstones, ulcers, and more19.Gastric Bypass (Roux-en-Y) is a multistep surgical procedure involving balloon sizing of the upper stomach, tract creation for lesser curvature dissection using hook cautery, and stomach division with an endoscopic stapler. It includes the use of a circular stapler anvil, enteroenterostomy with linear staplers, and retrocolic passage of the proximal Roux limb. A Penrose drain is used for this passage, and air leakage is checked during distension20. The adjustable gastric band induces weight loss by promoting early satiety and reducing appetite, impacting esophageal and proximal gastric functions through the vagus nerve21. Postoperative %EWL varies between 25.3 and 71.7%, with mean %EWL of 30% at 6 months, 40% at 12 months, 50% at 24 months, and 50–60% at 48 months in one study22. Long-term follow-up shows a mean BMI below 30 kg/m2 in patients followed for over 5 years, compared to a mean preoperative BMI of 42 kg/m2. Complications include gastric perforation, bleeding, port infection, conversion to open surgery, and death as early complications, and late complications such as band erosion, food intolerance, and access port problems22.In the Adjustable Gastric Banding (Lap-Band) procedure, a Nathanson liver retractor is inserted through a 5-mm incision below the xiphoid to retract the left hepatic lobe. Two atraumatic graspers are used to manipulate the stomach and create a passage for the band around the stomach, with gastric-to-gastric sutures to align it above and below the band11. Initially, a SG is performed, followed by transection of the small bowel 250 cm proximal to the ileocecal valve. The alimentary limb is anastomosed to the transected portion of the duodenum to form the duodenoileal anastomosis, and an ileoileal anastomosis is created 100 cm proximal to the ileocecal valve. The procedure concludes with suturing the surgical wounds23. Biliopancreatic diversion results in early weight loss due to SG and long-term weight loss from fat malabsorption. Hormonal changes, including reduced ghrelin and increased peptide YY levels, lead to early satiety. Gastrectomy affects ghrelin changes, while rapid nutrient entry into the ileum and jejunum after the distal bypass increases peptide YY levels11. Despite being less common than other bariatric procedures, biliopancreatic diversion achieves impressive long-term weight loss, ~70% %EWL24. Common complications include anastomotic leak, hemorrhage, and nutritional deficiencies. Other complications involve abdominal wall hematoma, wound infections, atelectasis, cholecystitis requiring cholecystectomy, and trocar site hernia, which can be surgically repaired25.The biliopancreatic diversion procedure involves three main components: creating a stomach tube with pylorus preservation, performing distal ileoileal anastomosis, and establishing proximal duodenal-ileal anastomosiset al.12 reported impressive average %EWL figures: ~67.1% at 6 months, 81.2% at 1 year, and 83.8% at 2 years post-surgery. Even in the long run, SG showed promise, with %EWL ranging from 41.8% among 179 patients to 64.1% among 14 patients observed at the 72-month follow-up13. Gastric bypass also demonstrated significant efficacy, achieving an average %EWL of 77% at 1 year and maintaining the results throughout the 60-month follow-up16. However, the average %EWL at 10 years after surgery showed a decreasing trend, ranging between 34 and 80.2%18. On the other hand, adjustable gastric banding yielded more modest outcomes compared to other procedures, resulting in a %EWL of 30% at 6 months and 50–60% at 48 months during the follow-up period22. Conversely, BPD/DS emerged as one of the most effective options, with an impressive average %EWL of ~70%, sustained even at long-term follow-ups24.The reviewed literature compared various weight loss procedures; among them, SG was a highly effective option for significant weight reduction Table . Durmush26. Similar outcomes were observed in another study with BPD/DS demonstrating the highest % total weight loss, followed by RYGB and SG27. Further analyses revealed that BPD/DS outperformed other procedures regarding weight loss outcomes28. Contrarily, a systematic review showed no significant differences in midterm and long-term weight loss outcomes between Laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG29. Another study compared laparoscopic adjustable gastric banding (LAGB) and laparoscopic gastric bypass, showing better weight loss results favoring gastric bypass30. Other studies reported consistent findings, with laparoscopic gastric bypass demonstrating superior weight loss compared to LABG31. In a comprehensive study encompassing various hospitals, laparoscopic gastric bypass showed the greatest average BMI reduction compared to LSG and LABG32.Comparative studies have also been conducted on various weight loss procedures. One study compared SG to RYGB and BPD/DS. BPD/DS showed the greatest BMI change after a year, followed by RYGB and SGet al.12, SG contributed to the complete resolution and significant improvement of type 2 diabetes in 71 and 18% of patients, respectively. It also resulted in the resolution of hypertension in 39% and improvement in 33% of patients. Similar results were found in the study by Neagoe et al.13, with 65.8% experiencing resolution or significant improvement in type 2 diabetes. In contrast, gastric bypass showed clinical reversal of diabetes mellitus in an impressive 98% of patients16. Although adjustable gastric banding can improve comorbidities, the outcomes may not be as significant as SG and gastric bypass. BPD/DS stands out as a highly effective procedure, improving obesity-related comorbidities and providing substantial health benefits to patients.BPD/DS and RYGB demonstrate the most favorable outcomes when examining the impact on obesity-related comorbidities. In the study by Durmush et al., with probabilities 1.88 times greater than SG. Even after BPD/DS, the probabilities of GERD resolution were 1.57 times greater, possibly due to a larger pouch and acid and bile diversion further downstream. They also noted that BPD/DS and RYGB were best for resolving type 2 diabetes and hypertension, outperforming SG. When comparing the chances of resolving obstructive sleep apnea (OSAS), RYGB, and BPD/DS showed equivalent probabilities, 1.46 and 1.76 times higher, respectively, compared to SG26. In the Bariatric Surgery Network study comparing comorbidities, they reported resolution or improvement rates of 44%, 68%, and 79% after 1 year for LAGB, LSG, and LRYGB, respectively, in terms of hypertension. For diabetes, the rates were 44%, 55%, and 83% for LAGB, LSG, and LRYGB, respectively. In patients with hyperlipidemia, the rates were 33%, 35%, and 66% for LAGB, LSG, and LRYGB, respectively. For patients with OSAS, the rates were 38%, 62%, and 66% for LAGB, LSG, and LRYGB, respectively. For GERD, the rates were 64%, 50%, and 70% for LAGB, LSG, and LRYGB, respectively. They concluded that LRYGB had the most significant outcomes for diabetes, hypertension, sleep apnea, and hyperlipidemia, followed by LSG and then LAGB. However, for GERD, LSG appeared less effective compared to LAGB, and LRYGB32.Regarding GERD, RYGB demonstrated the highest resolution, according to Sudan 2 and without obesity-related comorbidities  for arthritis may need to be more suitable candidates. Additionally, daily multivitamin intake is necessary, so patient commitment is essential. The gastric bypass carries the risk of severe perioperative complications, such as anastomotic or staple line leaks, occurring in ~4% of cases and may require re-operation. Other potential adverse effects include stomal stenosis, nutrient deficiencies, and internal hernia formation, all of which must be considered during patient selection30. BPD/DS is highly effective but typically recommended for patients with severe obesity and significant health risks. Careful evaluation is necessary to assess the patient’s suitability for this complex procedure, as it requires vitamin replacements due to potential malabsorption. Performing BPD/DS also demands specialized surgical skills, and it carries the highest incidence of adverse effects26.Adjustable gastric banding may be more suitable for patients who prefer a less permanent solution or have concerns about more extensive surgeries. It is less invasive, reversible, and associated with less serious side effects, leading to faster postoperative recovery and shorter hospital stays. However, it may be more appropriate for individuals with a lower BMI and fewer obesity-related health issues26. BMI is a crucial consideration, with higher BMI potentially indicating the need for more extensive procedures like gastric bypass or BPD/DS27. Surgical risks and patient preferences, including the desire for a reversible or permanent solution, also play a crucial role in the decision-making process28. Furthermore, the patient’s lifestyle and commitment to long-term changes, such as dietary modifications and regular exercise, are essential factors regardless of the procedure29. The experience and expertise of the bariatric surgeon are equally critical in selecting the most appropriate procedure for each patient, ensuring optimal outcomes and minimizing potential complications30. A comprehensive evaluation of these factors is essential to tailor the weight loss procedure to the individual’s needs and health circumstances.Several factors influence the choice of weight loss procedure for each patient. Medical history and obesity-related health conditions are significant determinants in selecting the most suitable option33. It can remain for up to 6 months, requiring endoscopic removal, and is effective when combined with lifestyle modifications34. In a study of adults with BMIs from 30 to 40 kg/m2, one group received the IGB and lifestyle advice, while the other received lifestyle intervention alone. The IGB group had significantly greater short-term weight loss at 3 and 6 months after removal, but some experienced adverse gastrointestinal events, leading to early balloon removal. A small percentage showed gastric abnormalities at removal35. In a post-marketing clinical trial, 8.9% of adults with BMIs of 30–40 kg/m2 experienced device and procedure-related serious adverse events (SAEs) with the IGB, below the 15% threshold. Combining the IGB with lifestyle intervention led to significant weight loss, supporting its use as an adjunct for weight reduction, with lower SAE rates in real-world clinical settings36. IGB therapy for super-obese patients showed short-term weight loss of 9.04% and a BMI reduction of 3.8 at 60 months postoperatively. However, more durable weight loss was achieved when IGB was combined with definitive bariatric surgeries, though three deaths (1.4%) were reported in the study37.The Intragastric Balloon (IGB) is a minimally invasive weight management tool – a single silicone sphere filled with saline, endoscopically placed in the stomach38. It is generally well-tolerated for the first 6 months but can pose technical challenges during insertion and removal. A study by Giuricin found that the Heliosphere BAG led to a mean weight loss of 12.66 kg and an overweight loss of 24.37% during a 6-month treatment period for severely obese patients. At 18 months post-removal, the mean BMI was 37.28 kg/m2, with a mean weight loss of 9.8 kg or 18.2%. The study suggested using the balloon as a ‘bridge treatment’ before major surgery to mitigate preoperative risks for severely obese patients39. Another study by Lecumberri et al. showed significant weight loss and BMI reduction with the Heliosphere IGB in 84 patients before bariatric surgery. Mean weight loss was 14.5 kg, BMI loss was 5.3 kg/m2, and 70.4% achieved a body weight loss of over 10%. The %EWL reached 33.2%. Age and initial BMI inversely affected weight loss outcomes40.The Heliosphere balloon is an air-filled polyurethane IGB designed to reduce side effects like nausea and vomiting2 who have not succeeded in losing weight through supervised programs41. It is implanted endoscopically and can be adjusted during its 8-month usage period before endoscopic removal. In a clinical study, 92% of Spatz3 Adjustable Balloon recipients experienced at least a 5% reduction in total body weight, with an average weight loss of 15.0%41. However, it is not suitable for individuals with specific medical conditions. It should be part of a long-term supervised diet and behavior modification program to enhance weight loss chances after removal. A study by Russo et al. compared the Spatz Adjustable Balloon System (ABS) with the BioEnterics Intragastric Balloon (BIB) for temporary obesity treatment. Both procedures resulted in similar median weight loss and BMI reduction at the end of therapy. Complications during the procedure and removal were minimal, with some cases of intolerance, gastrectasia, vomiting, and bowel migration. Weight gains were observed in the Spatz ABS group compared to the BIB group during follow-ups42. In addition to the Spatz balloon, other IGB devices like the ReShape Duo dual balloon system, Obalon system, and Elipse balloon are effective for promoting weight loss45. These balloons reduce food intake, promote fullness, delay gastric emptying, and influence hunger and satiety hormones. The choice of balloon depends on individual characteristics and medical advice.The Spatz balloon is an adjustable IGB filled with saline, designed for adults with a BMI between 30.0 and 40.0 kg/m2 who have not succeeded in losing weight through nonsurgical means46. It involves a tube attached to a Skin-Port port outside the abdomen. After each of their three daily meals, patients open the port valve, connect tubing, and allow gravity to drain stomach contents into a toilet or container. In a 52-week trial, the AspireAssist group achieved a significant 12.1% body weight loss at 52 weeks compared to 3.5% in the Lifestyle Counseling group, with a difference of 8.6%. This procedure also led to better excess weight loss, improved cardiometabolic risk factors, and enhanced quality of life. It demonstrated a favorable safety profile and high procedural success. More research is needed for long-term effects and broader applicability47. Another study involved 201 participants who underwent aspiration therapy between 2012 and 2016, resulting in promising weight loss outcomes , improved cardiometabolic parameters, and minimal complications. However, some participants discontinued the therapy for various reasons, necessitating further research to understand its benefits and drawbacks48. In a shorter 4-week study, 25 obese individuals achieved a considerable weight loss of 16.5 ± 7.8 kg, suggesting that the AspireAssist device may be a valuable tool for managing obesity49.The AspireAssist device is an option for adults with a BMI between 35.0 and 55.0 kg/m51. Abu Dayyeh et al. studied ESG’s efficacy and safety for treating classes 1 and 2 obesity. They found that ESG and lifestyle modifications led to significant and sustained weight loss up to 104 weeks and improved metabolic comorbidities. ESG is considered a safe and effective weight loss intervention for individuals with class 1 or 2 obesity, but more research is needed to assess its long-term durability and effectiveness in larger populations52.Endoscopic Sleeve Gastrectomy (ESG) is a minimally invasive weight loss procedure that uses an endoscope to reduce the size and reshape the stomach into a tubular structure. This procedure can lead to calorie intake reduction and weight loss. It offers advantages like fewer complications, shorter hospital stays, and quicker recovery compared to traditional bariatric surgerieset al.’s study supported the short-term effectiveness and safety of ESG using the Overstitch system for patients with classes I and II obesity. They observed significant weight loss at 6 months and 12 months, along with substantial excess BMI loss. The safety profile was favorable, with minimal complications53. A systematic review comparing LSG to other bariatric procedures, such as LGB and LAGB, found that LSG was well-tolerated, had a lower complication rate than LGB, and showed promising short-term weight loss outcomes. LSG also demonstrated potential in treating T2DM54.Neto 2 or 35 kg/m2 with obesity-related comorbidities55  or total  weight loss64. This highlights the importance of regular follow-up in supporting the patient’s weight loss journey and achieving successful outcomes after bariatric surgery.Studies have shown that adherence to postoperative follow-up significantly impacts the clinical outcomes of bariatric surgery56. Before bariatric surgery, candidates undergo a psychological evaluation to assess their readiness for the procedure and to address any potential psychosocial issues. Additionally, they are counseled to lose weight before surgery56. Registered dietitians play a crucial role in working with patients to develop personalized meal programs that meet their nutritional needs, facilitate weight loss, and promote overall health.Psychological and nutritional support are essential for an effective bariatric multidisciplinary team65. Educating patients about nutrition and its impact on successful weight loss is also vital to preoperative and postoperative care. Guiding food choices, portion control, and eating techniques empowers patients to make sustainable changes to their eating habits65.As obesity is considered a form of high-energy malnutrition, patients are often placed on a very low-energy diet (VLED) for 2–4 weeks before surgery. This approach helps reduce the size of the liver by 25%, thereby decreasing the risk of operative complications66. The postoperative follow-up serves as a platform to address psychosocial issues that may arise after bariatric surgery67. While the primary goal of bariatric surgery is to improve the quality of life for obese patients, not all patients who achieve weight loss experience significant improvements in their overall well-being67.Following the surgery, the multidisciplinary team continues to offer psychological support to ensure effective weight loss67, some common psychosocial issues patients encounter after bariatric surgery include concerns about excess skin, social support changes, struggles with illicit drug use disorders, and severe depression and suicidal thoughts. Addressing these psychological challenges is crucial to supporting the patient’s long-term success and well-being after the surgery.According to Kalarchian and Marcus5. However, it is not without risks, with complications falling into early (immediate postoperative) and late (after 30 days) categories68. Early complications include infections, bleeding, anastomotic leaks, pulmonary embolism (PE), and gastrointestinal issues like obstructions or perforations68. Timely medical attention and potential surgical intervention are crucial to manage these. Late complications manifest beyond the immediate postoperative period and include nutritional deficiencies, gallstones, gastrointestinal ulcers, hernias, and internal herniation68. Nutritional deficiencies stem from reduced nutrient absorption in some procedures, requiring ongoing monitoring and supplementation.Bariatric surgery is a popular and effective option for obesity, modifying the digestive system to promote weight lossWhile complications can occur, bariatric surgery is generally safe, with varying risks based on the procedure, patient health, and surgical team expertise. Preoperative assessments, patient selection, and postoperative care are vital for minimizing risks and optimizing outcomes. Patients considering bariatric surgery should undergo a thorough evaluation, receive counseling, and understand potential risks and benefits. Postoperative care and follow-up are essential for addressing complications and supporting the patient’s weight loss journey.69. The prevalence of SSI is a matter of concern due to its association with increased nosocomial morbidity and mortality rates69. These infections can range in severity from relatively mild surface incisional infections to more serious complications, such as intra-abdominal abscesses involving deep organ spaces and the development of incisional hernias71.Over the years, the field of surgery has made significant advancements in medical knowledge and infection control measures. However, surgical site infections (SSI) continue to be a persistent and concerning issue in healthcare institutions74. For instance, research by Kushner et al. found that patients with class I obesity have a 50% higher risk of SSI compared to individuals with a normal BMI. Patients classified as class II obese face an 86% higher risk, and patients with class III obesity experience a risk exceeding 100% higher than those with a normal BMI72. Several factors contribute to the risk of SSIs, including changes in respiratory physiology, modifications in the skin and soft tissue integrity, the presence of comorbidities like T2DM and cardiovascular disease, drug therapies, and antimicrobial resistance68.The rise in SSI has been linked to the increasing prevalence of higher BMI in patients undergoing surgery, with a progressive increase in infection risk as BMI categories increaseet al.71 revealed that the incidence of wound infection following bariatric surgery varies, with reported rates ranging from as low as 1% in the International Bariatric Surgery Registry to as high as 16.5% in several published studies. The bacterial isolates found in the study encompassed a range of microorganisms, with Staphylococcus aureus accounting for 39% of the isolates, alpha-hemolytic Streptococcus at 26%, Enterococcus at 16%, Proteus mirabilis at 9%, and various other bacteria collectively comprising 10% of the isolates71.Another study conducted by Christou Addressing the risk of SSIs in bariatric surgery and other procedures requires a comprehensive approach. Healthcare institutions and surgical teams must implement strict infection control measures, adhere to evidence-based guidelines, and tailor preventive strategies to address the unique risks associated with each patient. Proper preoperative evaluation, optimization of patient health, and meticulous postoperative care are essential to reducing the incidence of SSIs and improving overall surgical outcomes for patients.76. UTIs can occur at any point along the urinary tract, including the urethra, bladder, ureters, or kidneys. During bariatric surgery, the use of urinary catheters is often necessary to facilitate urine drainage and monitor output. However, this practice also introduces potential risks, as catheters can serve as a pathway for nosocomial bacteria to enter the urinary tract, leading to UTIs76.Urinary tract infection (UTI) is a common postoperative complication of bariatric surgery, affecting over 40% of patients and accounting for a significant portion of nosocomial infections, with ~1.7 million patients affected annuallyEscherichia coli (E. coli) is the primary causative agent, responsible for over 90% of cases. Similarly, ~50% of nosocomial catheter-associated UTIs (CAUTIs) are attributed to E. coli infections77. The duration of urinary catheterization also plays a crucial role in UTI risk. Patients with catheters in place for more than 2 days are twice as likely to develop a UTI compared to those with catheterization lasting 2 days or less76. Apart from urinary catheter use, several other risk factors have been identified in previous studies. These factors include age, with older patients being more susceptible to UTIs, longer operative times during surgical procedures, and prolonged hospital stays, which increase exposure to healthcare-associated infections79.In ambulatory patients diagnosed with a UTI, To reduce the risk of UTIs following bariatric surgery, healthcare providers must adhere to strict infection prevention protocols. This may involve minimizing the duration of urinary catheterization whenever possible, using aseptic techniques during catheter insertion and maintenance, and employing prophylactic antibiotics when indicated. Additionally, healthcare professionals should be vigilant in monitoring patients for signs and symptoms of UTIs and promptly initiate appropriate treatment when infections are identified. By addressing these risk factors and implementing effective preventive measures, healthcare teams can help reduce the incidence of UTIs in bariatric surgery patients and improve overall postoperative outcomes.81.Gastrointestinal leaks, also known as anastomotic leaks or gastric leaks, are serious and potentially life-threatening complications that can occur after certain gastrointestinal surgeries, including bariatric surgeries. While the incidence of postoperative gastrointestinal leaks has decreased over the years, it remains a relatively infrequent complication that carries a significant risk of morbidity and mortality82. It is important to note that the location of the anastomosis and the type of surgery performed can significantly impact the risk of leaks.The rates of leaks after gastrointestinal surgeries vary depending on the specific site of the anastomosis. For instance, leak rates are observed in the range of 2–16% for the esophagus, 1–9% for the stomach, 9–16% for the pancreas, 10–16% for the bile ducts, 1–3% for the small intestine, 3–29% for the colon, and 8–41% for the rectum82.Gastrointestinal leaks can lead to various complications, including intra-abdominal abscesses, sepsis, and other infections, which can further contribute to morbidity and mortality. The severity of these leaks can range from mild and self-limiting to severe and life-threatening. Mortality rates associated with gastrointestinal leaks can be as high as 35%, emphasizing the importance of early detection and prompt interventionTo minimize the risk of gastrointestinal leaks, surgeons follow meticulous surgical techniques and employ advanced technologies, such as intraoperative leak testing, to ensure the integrity of the anastomosis. Additionally, postoperative monitoring and early recognition of signs and symptoms of leaks are crucial for timely intervention and management.Patients undergoing gastrointestinal surgeries, including bariatric procedures, should be educated about the potential risks and signs of complications, including gastrointestinal leaks, so that they can seek medical attention promptly if needed. By adopting comprehensive preventive measures and maintaining a high index of suspicion for leaks in the postoperative period, healthcare teams can work together to reduce the incidence of gastrointestinal leaks and improve patient outcomes after bariatric and other gastrointestinal surgeries.84. A study carried out by Stein and Matta83 revealed that the in-hospital prevalences of PE, DVT, and VTE following bariatric surgery were found to be 0.9%, 1.3%, and 2.2%, respectively.The reported incidence of venous thromboembolism (VTE), which includes PE or deep vein thrombosis (DVT), following bariatric surgery exhibits significant variability, ranging from 0% in some studies to as high as 3.5% in others85. The mechanism behind this increased risk is attributed to factors such as venous stasis caused by abdominal adiposity, endothelial dysfunction, and the pro-inflammatory and prothrombotic state associated with obesity87.Obesity itself is a significant risk factor for VTE, particularly symptomatic DVT. The combination of obesity and abdominal surgery that necessitates general anesthesia for ~30 min or more further increases the risk of thrombosis, leading to a 10-fold increased risk for the development of VTE86. As patients undergoing bariatric procedures may include older individuals, advanced age can contribute to an increased risk of postoperative complications, including VTE.Age is also a notable risk factor for adverse events following bariatric surgery, including VTETo mitigate the risk of VTE following bariatric surgery, several preventive measures are implemented. These may include the use of pharmacological prophylaxis (such as anticoagulant medications) and mechanical prophylaxis (such as pneumatic compression devices) to enhance blood flow and prevent clot formation. Early ambulation and patient mobilization after surgery are also essential to reduce the risk of venous stasis.It is crucial for the multidisciplinary team caring for bariatric surgery patients to identify those at higher risk for VTE and tailor the prophylactic measures accordingly. By implementing comprehensive VTE prevention strategies, healthcare providers can reduce the incidence of postoperative complications and optimize patient outcomes following bariatric surgery. Regular monitoring and prompt detection of any signs or symptoms of VTE can further contribute to early intervention and improved patient care.87.Long-term nutritional deficiencies and monitoring are essential in managing patients who have undergone bariatric surgery. Weight loss procedures, such as gastric bypass, SG, and biliopancreatic diversion, can alter the gastrointestinal anatomy and the absorption of nutrients, causing deficiencies in iron, calcium, and various vitamins, including vitamins D, B1, B9, and B1288.These deficiencies can lead to specific health conditions such as anemia due to iron deficiency, osteopenia (reduced bone density), and neurological symptoms resulting from vitamin B12 deficiency. Other malnutrition-related complications have been observed following gastric bypass surgery (GBP), such as protein malnutrition and vitamin A deficiency, which may cause ocular complications89. Among these deficiencies, iron, vitamin D3, and folic acid deficiencies were notably more frequent in the first year compared to the second year after the surgery89.Monitoring for postoperative deficiencies is crucial as they can arise anytime. However, most deficiencies are commonly observed between 12 and 15 months after the surgery, except for vitamin D3, which may occur earlier90. Early postoperative deficiencies often correspond with the most common preoperative deficiencies, suggesting that nutritional imbalances existing before the surgery may persist after the procedure. This highlights the importance of preoperative nutritional assessments and interventions to optimize the patient’s nutritional status before bariatric surgery89.Various factors can contribute to postoperative nutritional deficiencies, including preoperative deficiencies, intolerance to certain foods after surgery, alterations in taste and eating patterns, and non-adherence to dietary and supplement recommendations post-surgeryTo address and prevent nutritional deficiencies, bariatric surgery patients should receive ongoing nutritional counseling and follow-up care from registered dietitians as part of the multidisciplinary team. The dietitians work closely with patients to develop personalized meal plans and supplement recommendations to ensure adequate intake of essential nutrients. Regular blood tests are typically conducted to monitor the patient’s nutritional status and detect deficiencies early, allowing prompt interventions.Long-term nutritional monitoring and follow-up are crucial to ensuring bariatric surgery patients’ overall health and well-being and to minimize the risk of complications related to nutritional deficiencies. By actively addressing and managing nutritional issues, healthcare providers can enhance the success and safety of bariatric surgery as a weight loss and metabolic health intervention.91. The evaluation typically includes psychological testing, nutrition evaluation, and medical assessment. Medical evaluation involves laboratory testing, including complete blood counts, metabolic profiles, coagulation profiles, ferritin levels, thyroid function testing, and lipid profiles91. For those undergoing malabsorptive procedures, vitamin B12 and fat-soluble vitamin levels may be considered92.During the preoperative evaluation of patients considered for bariatric surgery, healthcare providers conduct a comprehensive assessment to determine their candidacy and identify potential factors that may impact the procedure’s success92.Pulmonary and cardiac assessments are also essential components of the preoperative evaluation. This may involve conducting chest radiographs, arterial blood gas measurements, pulmonary function tests, electrocardiograms, and stress tests to assess coronary artery disease. Given the prevalence of obesity-related sleep apnea, a sleep study may also be part of the evaluationHelicobacter pylori infection is recommended for patients undergoing bariatric surgery. Positive H. pylori testing has been associated with a higher likelihood of abnormal endoscopy and postoperative marginal ulcers. If H. pylori infection is detected, preoperative therapy for eradication is advised92.Preoperative testing for 93.Furthermore, liver histology is assessed as obesity often presents with nonalcoholic fatty liver disease. Gastric bypass surgery has shown significant improvement in liver histology for most patients. Preoperative evaluation involves blood testing and imaging studies, such as ultrasonography, with a liver biopsy performed if cirrhosis is suspected91. A thorough preoperative evaluation by bariatric behavioral clinicians is essential to identify risk factors affecting surgical success and weight loss goals. This evaluation fosters a trusting relationship between the clinician and the patient, allowing for tailored interventions and support throughout the weight loss journey93.Psychosocial factors significantly impact the long-term outcomes of bariatric surgery, affecting adherence to postoperative lifestyle recommendations, emotional adjustment, and weight loss outcomes94. However, adherence to these postsurgical recommendations has been closely linked to the procedure’s success in terms of weight loss95.Adherence to professional recommendations is a critical aspect of post-bariatric surgery care, and it encompasses following dietary guidelines, engaging in physical activity, attending medical follow-ups, and participating in support group sessions. Despite its importance, studies have shown that preoperative and postoperative noncompliance with these recommendations is relatively common89. During the first year after surgery, patients experience rapid weight loss, which puts them at risk for deficiencies in vitamins and minerals, dehydration, and gastrointestinal symptoms88. Proper dietary management and supplementation are essential to prevent complications arising from these deficiencies and to ensure overall patient safety and well-being88. Regular screenings for anemia, clotting abnormalities, and nutrient deficiencies are also vital to detect any potential imbalances or deficiencies that could negatively impact the patient’s health95.Nutritional care after bariatric surgery is paramount for successful wound healing and overall well-being95. Addressing these concerns early can improve outcomes and ensure patients achieve their weight loss goals.Monitoring weight loss progress is an essential part of post-bariatric surgery care. Unsuccessful weight loss or significant weight gain may signal potential issues that require additional support and prompt intervention from the healthcare teamEngagement in physical activity is another crucial aspect of post-bariatric surgery care. Regular exercise can enhance weight loss, improve cardiovascular health, and improve the patient’s overall well-being. Healthcare providers should encourage patients to adopt an active lifestyle and provide guidance on suitable exercise routines based on their needs and capabilities.Participation in support group sessions can also benefit patients undergoing bariatric surgery. Support groups offer a valuable platform for patients to share their experiences, challenges, and successes with others who have undergone similar procedures. These groups can provide emotional support, practical advice, and a sense of community, positively impacting the patient’s overall experience and long-term success.et al. demonstrated that many participants who underwent bariatric surgery could maintain their weight loss long-term, with almost half of the individuals maintaining their weight within 20% of the lowest weight achieved after the surgery. This long-term weight maintenance was superior to the outcomes observed in a nonsurgical comparison group of individuals with severe obesity96. This highlights the effectiveness of bariatric surgery as a long-term weight control strategy.The study conducted by Ryder 97 In a study by Svetkey et al., participants who received personalized contact through monthly telephone or face-to-face interactions with healthcare professionals demonstrated significantly better weight loss retention compared to those in self-directed or interactive technology intervention groups98. This emphasizes the importance of ongoing support and guidance from healthcare professionals in helping patients sustain their weight loss efforts.Regular and continuous communication between patients and healthcare providers is essential to ensure successful long-term weight maintenance.et al.99, which focused on patients who underwent RYGB, revealed that those who engaged in at least 150 min per week of moderate-intensity physical activity experienced greater weight loss at 6 and 12 months after the surgery. Physical activity contributes to weight loss, offers numerous health benefits, and supports overall well-being.Consistent engagement in physical activity is also recognized as a key strategy for ensuring long-term weight maintenance. The study by Evans 100Bariatric surgery has been shown to promote significant weight loss and lead to substantial improvements or even resolution of obesity-related comorbidities. Conditions such as T2DM, hypertension, and cardiovascular diseases, which are often associated with obesity, have been found to improve after bariatric surgery.et al. in 2012 investigated the impact of gastric bypass surgery on adults with uncontrolled or medication-controlled type 2 diabetes. Over 13 years, 4434 adults underwent gastric bypass, and within 5 years after surgery, ~68.2% of them experienced complete remission of diabetes101. This study demonstrated the significant potential of bariatric surgery in achieving diabetes remission and improving glycemic control.A retrospective cohort study conducted by Arterburn et al.102 conducted a study that showed that achieving the resolution of hypertension through weight loss reduced the risks of coronary arterial disease (CAD) by ~39% in men and 25% in women. This highlights the cardiovascular benefits of weight loss achieved through bariatric surgery.Hypertension is another common comorbidity associated with obesity, and weight loss-induced resolution of hypertension can significantly reduce cardiovascular risk in patients. Vogel Bariatric surgery has been associated with decreased prevalence and improvement in the severity of various mental health conditions, focusing on improvements in depression.et al.103 found that among individuals seeking and undergoing bariatric surgery, the most prevalent mental health conditions were depression, with an estimated prevalence of 19%, and binge eating disorder, with an estimated prevalence of 17%. However, the study also revealed that bariatric surgery consistently correlated with postoperative reductions in the prevalence of depression, with improvements ranging from 8% to 74%. Notably, the severity of depressive symptoms also showed improvement following the surgical procedure103.A study conducted by Dawes 103.The observed improvements in depression and other mental health conditions after bariatric surgery can significantly impact patients’ overall well-being and quality of life. Weight loss, changes in hormonal factors after surgery, and increased self-esteem and body image perception have been suggested as potential factors contributing to improving mental health outcomes104. While this diversity aptly mirrors the intricate nature of the field, it simultaneously introduces complexities when attempting direct comparisons and generalizing findings across disparate studies104. Therefore, a promising direction for future research involves adopting standardized protocols and rigorous, expansive trials to enhance the reliability and quality of the presented evidence.In the context of this review on recent advancements in bariatric surgery, it is crucial to acknowledge certain limitations arising. Bariatric surgery research presents a diverse landscape encompassing various study designs, patient groups, and chosen outcome measures105. However, the critical factor of long-term sustainability necessitates deeper exploration. Attaining a comprehensive understanding of the durability of weight loss, metabolic enhancements, and potential complications over extended periods is crucial to guide informed clinical decision-making. Beyond conventional clinical endpoints, the incorporation of patient-centered outcomes assumes heightened significance. While achieving weight loss and metabolic improvements remains pivotal, an equally vital facet involves comprehending the broader impact of these procedures on aspects such as overall quality of life, psychological well-being, and patient satisfaction. This holistic perspective promises a deeper understanding of the intricate implications of bariatric surgery on individuals.The immediate benefits observed in several modern bariatric procedures are undeniably compellingFuture research endeavors would benefit from robust comparative studies to inform tailored and personalized surgical decisions. Directly comparing different techniques can offer a nuanced understanding of distinct advantages and disadvantages, aiding practitioners in making informed choices based on patient profiles. Similarly, recognizing that the effectiveness of bariatric surgery extends beyond the operating room, the integration of multidisciplinary care gains prominence. Collaborative efforts involving nutritionists, psychologists, and exercise specialists stand poised to optimize patient outcomes. Therefore, further research investigating the seamless integration of these components into the overarching bariatric care framework is warranted.106. The potential of technology to reshape procedural success rates and patient recovery experiences beckons further exploration, making the study of these technological innovations and their tangible impact a compelling avenue for future research. In addition, the persistent challenge of health disparities demands continuous attention in bariatric surgery107. To this end, dedicated research aimed at dissecting and mitigating factors contributing to differential access, treatment outcomes, and overall experiences among diverse patient populations remains imperative.Technological advancement holds considerable promise for refining bariatric procedures, encompassing innovative surgical tools, advanced imaging methods, and minimally invasive approachesBariatric surgery encompasses a range of well-established weight loss procedures, each with distinct mechanisms and outcomes. Additionally, emerging options like IGBs, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further research to solidify their effectiveness. Nevertheless, bariatric surgery has consistently demonstrated substantial benefits in weight loss, comorbidities resolution, and quality of life improvements. By tailoring procedures to individual needs and continuing research efforts, the field is poised for advancement, leading to improved patient outcomes and transformative changes in the lives of those seeking effective weight loss solutions.Ethics approval was not required for this review.Informed consent was not required for this review.None.N.A.: conceptualization. All authors were involved in writing the manuscript.All authors declare no conflicts of interest.Nicholas Aderinto.Data sharing is not applicable to this article.Not commissioned, externally peer-reviewed.


Obesity is a complex, multifactorial and chronic disease. Bariatric surgery is a safe and effective treatment intervention for obesity and obesity-related diseases. However, weight loss after surgery can be highly heterogeneous and is not entirely predictable, particularly in the long-term after intervention. In this review, we present and discuss the available data on patient-related and procedure-related factors that were previously appointed as putative predictors of bariatric surgery outcomes. In addition, we present a critical appraisal of the available evidence on which factors could be taken into account when recommending and deciding which bariatric procedure to perform. Several patient-related features were identified as having a potential impact on weight loss after bariatric surgery, including age, gender, anthropometrics, obesity co-morbidities, eating behavior, genetic background, circulating biomarkers , psychological and socioeconomic factors. However, none of these factors are sufficiently robust to be used as predictive factors. Overall, there is no doubt that before we long for precision medicine, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions. Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, would enable a more precise identification of the causal links between determinants of weight gain and weight loss. Artificial intelligence algorithms to be used in clinical practice to predict the response to bariatric surgery interventions could then be created, which would ultimately allow to move forward into precision medicine in bariatric surgery prescription. Obesity is a complex, chronic and multifactorial disease . Weight 2 with co-morbidity  are associated with %EWL at 3 and 6 months after SG. In addition, serotonin and serotonin/5-hydroxytryptophan (5-HTrp) ratio were shown to depict a superior performance at predicting weight loss 3 months (ROC AUCs for serotonin: 0.78 and serotonin/5-HTrp ration: 0.81) and 6 months (ROC AUCs for serotonin: 0.79 and serotonin/5-HTrp ration: 0.80), after SG [Metabolomics recently emerged as a powerful tool to provide new insights on the pathological processes. Multiple studies have focused on the identification of metabolite profiles that could be used as biomarkers for diagnosis, disease monitoring and prognosis , 179. Meafter SG , with loThe anatomical gut rearrangement induced by bariatric surgery yields alterations in patients’ gut hormone profile , 183. Inet al found that preoperative responses of glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) to a mixed meal tolerance test (MMTT) do not correlate to short-term postoperative weight loss, after RYGB surgery [Werling  surgery . Another surgery . Higher  surgery .Moreover, SADI-S and RYGB with a biliopancreatic limb (BPL) of 200 cm seem to elicit a favorable post-prandial glucose, GLP-1 and insulin profile, with a potentially lower risk of protein malnutrition when compared to BPD-DS and lower risk of post-prandial hyperinsulinemia as compared to RYGB with a shorter BPL . The posDespite there are universally accepted indications for considering bariatric surgery and a vast array of surgical techniques is presented, there are no defined criteria for the use of each procedure nor guidelines for a patient-tailored decision among different technical procedures in order to optimize bariatric surgery outcomes. The decision to conduct a given procedure is empirical taking into account the individuals’ phenotype, the peri-operative risk and the surgeon experience, without any robust evidence based approach. This remains one of the most frustrating shortfalls in bariatric practice, both for clinicians and patients since weight loss after bariatric surgery is heterogeneous and can be highly unpredictable.Although the pre-operative factors with a greater impact on post-surgical weight loss are BMI, age and T2D, these are not sufficient to explain the diversity of bariatric surgery outcomes. In addition, genetic factors and food addiction were also demonstrated to be major determinants of weight loss after surgery; while miRNAs, metabolomics and hormonal profiling, although promising are far from being robust preoperative biomarkers to be implemented in clinical practice. Consequently, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions.Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, could enable a more precise identification of the causal links between the determinants of weight loss and weight gain. Artificial intelligence algorithms grounded on preoperative factors could then be created to be used in clinical practice to predict the response to bariatric surgery interventions Fig. . In a fu